|Year : 2018 | Volume
| Issue : 1 | Page : 24-27
Sleep patterns in Egyptian children with nocturnal enuresis
Adel S El Said1, Elham Abdel Ghafar Mohammady1, Mohamed M El Hamady2, Ashraf M Abdel Aal3, Hanaa R Omar1
1 Department of Pediatrics, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Neuropsychiatry, Faculty of Medicine, Benha University, Benha, Egypt
3 Department of Urosurgery, Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||06-Jan-2017|
|Date of Acceptance||02-Feb-2017|
|Date of Web Publication||28-Feb-2018|
Hanaa R Omar
Department of Pediatrics, Faculty of Medicine, Benha University, Benha, 13518
Source of Support: None, Conflict of Interest: None
Background Enuresis is widely regarded as parasomnia because it occurs only during the nonrapid eye movement sleep cycle. Polysomnography can be used to monitor appropriate physiological variables associated with children’s sleep-related problems.
Aim The aim of this study was to determine sleep patterns in Egyptian children who were suffering from primary nocturnal enuresis.
Patients and methods Twenty children with primary nocturnal enuresis and ten healthy children were included in our study. Patients were recruited from outpatient clinics of the Pediatric Department of Benha University Hospital, during the period between March 2015 and March 2016. The following investigations were carried out on all patients: urine analysis and culture, random blood sugar, Ca, Na+, creatinine, pelvic-abdominal ultrasound, lumbosacral radiograph, uroflowmetry, voiding cystometry, and polysomnography.
Results Uroflowmetric tests were normal in all cases excluding local urological causes of enuresis. Cystometric measurement of bladder capacity revealed that three out of 20 (15%) patients had reduced bladder capacity, and 17 (85%) patients had normal bladder capacity.
A statistically significant difference (P=0.001) was observed in the number of awakenings, where the patients showed a significantly higher number of awakenings. A statistically significant difference (P=0.002) was observed in delta-wave sleep, where the patients showed significantly less delta sleep activity and lower sleep efficiency compared with controls. Rapid eye movement sleep percentage was low in enuretic children, although the difference was not statistically significant (P=0.142).
Conclusion Monosymptomatic nocturnal enuresis can be explained by a multifactorial etiology. Sleep disturbances with consequent urodynamic findings seem to be the cornerstone of this problem.
Keywords: nocturnal enuresis, polysomnography, sleep patterns, urodynamic study
|How to cite this article:|
El Said AS, Ghafar Mohammady EA, El Hamady MM, Abdel Aal AM, Omar HR. Sleep patterns in Egyptian children with nocturnal enuresis. Benha Med J 2018;35:24-7
|How to cite this URL:|
El Said AS, Ghafar Mohammady EA, El Hamady MM, Abdel Aal AM, Omar HR. Sleep patterns in Egyptian children with nocturnal enuresis. Benha Med J [serial online] 2018 [cited 2021 Dec 5];35:24-7. Available from: http://www.bmfj.eg.net/text.asp?2018/35/1/24/226416
| Introduction|| |
Enuresis is one of the most common childhood problems in both pediatrics and psychiatry. It is defined as involuntary, repeated voiding of urine into clothes or bed after developmental age when bladder control should be established, mostly at the age of 5 years. The diagnosis of enuresis is made when urine is voided twice a week for at least 3 consecutive months .
Polysomnography is a laboratory test to detect sleep behavior, especially nighttime sleep behavior. It can be used to monitor the appropriate physiological variables associated with a child’s sleep-related problems. It should always be performed with sleep staging, especially in children. The recording channel is comprised of two electro-oculograms, an electroencephalogram (EEG), and a chin electromyogram. However, in children, extended EEG montage should be used because of the higher incidence of nocturnal behavior, which may be confused with seizure disorder. To detect EEG abnormalities that may persist, the night montage should include the frontal, central, temporal, occipital, and vertex electrodes.
| Patients and methods|| |
The present study was conducted on patients recruited from outpatient clinics of the Pediatric Department of Benha University Hospital, during the period between March 2015 and March 2016. Informed consents were obtained from parents of all included patients. The study was approved by the ethics committee of Benha University.
Twenty patients with primary nocturnal enuresis and ten healthy children (controls) were included. Patients were selected according to the following inclusion and exclusion criteria:
Inclusion criteria: Both sexes were included, patients’ age ranged between 5 and 14 years.
Exclusion criteria: children less than 5 years of age, those suffering from diurnal or diurnal and nocturnal enuresis, those suffering from any other urinary symptoms, those with mental retardation, and those with regressive enuresis were excluded.
All patients were subjected to the following: full history taking, assessment of the type of enuresis, its frequency (per week or night), association with any urological, neurological, or psychological disturbances, and previous therapeutic trial, and general examination including weight and height.
Systemic examination (with special emphasis on neurological and urological examination) and laboratory investigations (urine analysis and culture, random blood sugar, Na, Ca, creatinine, plain lumbosacral radiograph, pelvic-abdominal ultrasound, uroflowmetry, cystometry, and polysomnography) were carried out.
Data management and statistical analysis were performed using the statistical package for the social sciences (SPSS, Chicago, USA; version 23).
Numerical data are summarized using means and SDs or medians and ranges (if nonparametric). Suitable statistical tests of significance were performed. The level of significance was set at 0.05 (P<0.05).
| Results|| |
Our results are demonstrated in [Table 1] and [Table 2].
|Table 1 Comparison between patients and controls with regard to polysomnogram patterns|
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|Table 2 Comparison between enuretics with normal bladder capacity versus those with diminished bladder capacity with regard to polysomnogram patterns|
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| Discussion|| |
Nocturnal enuresis is classified as primary when the child has never been persistently dry throughout the night and as secondary when the child starts wetting the bed after 1 year of incontinence. Primary enuresis is very common and less likely to have a pathological cause .
Butler and Heron  reported that nocturnal enuresis affects 5–10% of children of primary school age and perhaps 0.5–1% of adults, and there are no major cultural or racial differences in nocturnal enuresis prevalence. Nocturnal enuresis is three times more common than daytime wetting and affects 6–7% of younger children and 2–8% of older children .
Primary nocturnal enuresis is caused by disparity between bladder capacity and nocturnal urine production and the child’s failure to awaken in response to a full bladder .
Weight and height centiles of patients were not statistically different from those of controls. Järvelin et al.  and Norgaard et al.  observed that enuresis was associated with short stature, possibly reflecting a deficiency in growth hormone secretion An explanation for this finding was given by Butler , who found that growth hormone release was impaired in children living in deprived social circumstances, where enuresis is indeed more common.
Similarly, Dundaroz et al.  found that growth and bone age were retarded in children with nocturnal enuresis. However, they attributed that delay to maturation in regulatory functions of the central nervous system.
In the present study, urodynamic evaluation was performed in all patients. Uroflowmetric tests were normal in all cases, except in patients with local urological causes of enuresis. Cystometric measurement of the bladder capacity revealed that three out of 20 (15%) patients had reduced bladder capacity and 17 (85%) patients had normal bladder capacity. Studies carried out by Kirk et al.  and Eller et al.  report that children with monosymptomatic nocturnal enuresis, especially those who failed to respond to desmopressin treatment, have smaller functional bladder capacity.
The studied parameters among our cases were not significantly different between enuretic patients with positive family history and patients without such a history; however, positive consanguinity was associated with presence of enuresis in more than one member of the family in comparison with those with negative consanguinity. Our results are in contrast with Gumus et al. , who reported that there was no effect of consanguinity on enuresis prevalence.
A statistically significant difference was observed in the number of awakenings during the total sleep time between patients and controls, where patients showed a significantly higher number of awakenings (P=0.001). In addition, a statistically significant decrease in delta-wave sleep was found in enuretic children as compared with normal children (P=0.002).
Wolfish et al. and Wolfish  demonstrated that enuretic children had elevated arousal thresholds mostly in the first 2/3 nights where nonrapid eye movement was predominant (indicating deep sleep).
However, our results differ from those of Boyd  and Reimao et al. , who reported no differences in depth of sleep between enuretic children and healthy controls. In addition, Averous et al.  reported that abortive rapid eye movement (REM) sleep episodes in the first part of the night may be more common in enuretic children than in normal children.
Koff  showed that there was no significant difference in sleep pattern of bedwetting children between nights with enuretic episodes and nights without enuretic episodes. In addition, Nevéus et al.  reported that total sleep time was not significantly different between dry children and enuretic ones.
Gillin et al.  also compared sleep patterns in 11 patients with nocturnal enuresis with ten controls, and found that the standard polysomnographic features were the same in both groups except that enuretic patients had more delta-wave activity.
The test was performed on four consecutive nights in the sleep laboratory, thus giving the patient a chance to adapt to the new sleeping environment. The increase in delta-wave activity appeared on the third night.
It was also found that in enuretic children the percentage of REM sleep is somewhat low compared with normal children ,, and REM latency is longer than expected .
In our study, REM sleep percentage was low in enuretic children compared with controls, although the difference was not statistically significant. This polysomnographic finding can perhaps be attributed to the first night effect. Another possibility is that abortive REM sleep episodes in the first part of the night might be more common in enuretic children than in normal children ,,.
Bader et al.  conducted a study on 21 patients with nocturnal enuresis and six controls at their homes (i.e. in the child’s natural sleep environment). They found that the sleep parameters for patients and controls were nearly the same except for the time spent in bed, which was longer in enuretic children with an increased number of sleep cycles. A larger control group might have provided more significant results.
| Conclusion|| |
Monosymptomatic nocturnal enuresis can be explained by a multifactorial etiology. Sleep disturbances with consequent urodynamic findings seem to be the cornerstone of this problem.
- Specialized clinics for proper diagnosis, reassurance, and treatment of nocturnal enuretic patients are recommended, as it imposes a stressful impact on their families.
- Management of nocturnal enuresis should be problem directed with special consideration of the polysomnogram and urodynamic assessment.
- Further studies on the following must be performed:
- Assessment of hormonal disturbances in enuretic patients, for example growth hormone.
- Good understanding of genetic factors in enuretic patients with positive family history and positive consanguinity.
- Assessment of central nervous system developmental regulation on detrusor muscle contractions and arousal system.
- Establishment of the best treatment guidelines for each category.
The authors thank all the doctors who participated in the present study, the parents of the patients, and the nursing staff.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Scott C, Datton R. Vegetative disorder. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson textbook of pediatrics. 16th ed. Philadelphia: WB Saunders Co.; 2000. p. 72.
Nevéus T. The role of sleep and arousal in nocturnal enuresis. Acta Paediatr 2003; 92:1118–1123.
Butler RJ, Heron. J. The prevalence of infrequent bedwetting and nocturnal enuresis in childhood: a large British cohort. Scand J Urol Nephrol 2008; 42:257–264.
Stein MA, Mendelsohn J, Obermeyer WH, Amromin J, Benca R. Sleep and behavior problems in school-aged children. Pediatrics 2001; 107:E60.
Hjälmas K, Arnold T, Bower W, Caione P, Chiozza LM, Von Gontard A et al.
Nocturnal enuresis: an international evidence based management strategy. J Urol 2004; 171(Part 2):2545–2561.
Järvelin MR, Moilanen I, Kangas P, Moring K, Vikeväinen-Tervonen L, Huttunen N-P et al.
Aetiological and Precipitating factors for childhood enuresis. Acta Pediatr Scand 1991; 80:361–369.
Norgaard JP, Djurhuus JC, Watanabe H, Stenberg A, Lettgen B. Experience and current status of research into the pathophysiology of nocturnal enuresis. Br J Urol 1997; 79:825–835.
Butler RJ. Nocturnal enuresis: the child’s experience. Butler RJ, editors. Oxford: Butlerworth Heinemann Medica; 1994. pp. 33–45.
Dundaroz MR, Sarici SU, Denli M, Aydin HI, Kocaog’lu M, Ozisik T et al.
Bone age in children with nocturnal enuresis. Int Urol Nephrol 2001; 32:389–391.
Kirk J, Rasmussen PV, Ritting S, Djurhuus JC. Micturation habits and bladder capacity in normal children and in patients with desmopressin resistant enuresis. Scand J Urol Nephrol 1995; 173(Suppl):49–50.
Eller DA, Austin PF, Tanguags S, Homsy YL. Daytime function-al bladder capacity as a predictor of response to desmopressin in monosymptomatic nocturnal enuresis. Eur Urol 1998; 33:25–30.
Gumus M, Vurgun N, Lekili M, Iscan A, Muezzinoglu T. Prevalence of nocturnal enuresis and accompanying factors in children aged 7–11 years in Turkey. Acta Pediatr 1999; 88:1369–1372.
Wolfish NM, Pivik RT, Busby KA. Elevated sleep arousal thresholds in enuretic boys: clinical implications. Acta Pediatr 1997; 86:381–384.
Wolfish NM. Sleep arousal function in enuretic males. Scand J Urol Nephrol Suppl 1999; 202:24–26.
Boyd MMM. The depth of sleep in enuretic school children and in non-enuretic controls. J Psychosom Res 1960; 4:274–281.
Reimao R, Pachellil C, Carneiro XX, Falwichow G. Primary sleep enuresis in children: polysomnographic evidences of sleep stage and time modulation. Arq Neuropsiquiatr 1993; 51:41–45.
Averous M, Robert M, Billiard M, Guiter J, Grasset D. The voiding control during sleep. Practitioner’s Rev 1991; 41:2282–2287.
Koff SA. Enuresis In: Walsh PC, editor. Campbell’s urology. 7th ed. Philadelphia: WB Saunders Co.; 1998. pp. 2055–2067.
Nevéus T, Hetta J, Cnattingius S, Tuvemo T, Lackgren G, Olsson U. Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr 1999; 88:748–752.
Gillin JC, Rapoport JL, Mikkelsen EJ, Langer D, Vanskiver C. EEG sleep patterns in enuresis: a further analysis and comparison with normal controls. Biol Psychiatry 1982; 17:947–953.
Hunsaballe JM. Increased delta component in computerized sleep electroencephalographic analysis suggests abnormally deep sleep in primary monosymptomatic nocturnal enuresis. Scand J Urol Nephrol 2000; 34:294–302.
Coble PA, Reynolds CF, Kupfer DJ, Houch P. Electroencephalgraphic sleep of healthy children, part II: findings using automated delta and REM sleep measurement methods. Sleep 1987; 10:551–562.
Inoue M, Shimojima H, Tsukahara N, Tajika Y, Taka K. Rhythmic slow wave observed on nocturnal sleep encephalogram in children with idiopathic nocturnal enuresis. Sleep 1987; 10:570–579.
Finely WW. An EEG study of the sleep of enuretics at three age levels, Clin Electroencephalog 1971; 2:35–39.
Norgaard JP, Hansen JH, Nielsen JB, Ritting S, Djurhuus JC. Nocturnal studies in enuretics: a polygraphic study of sleep − REG and bladder activity. Scand J Urol Nephrol 1989; 125:73–78.
Bader G, Nevéus T, Kurse J, Sillen U. Sleep of primary enuretic children and controls, Sleep 2002; 25:579–583.
[Table 1], [Table 2]